CT evaluation for ‘quiescent’ herniation following closure of diverting loop ileostomy

Aim The prevalence of abdominal wall herniation at the site of a previous temporary stoma is uncertain. This cohort study investigated the frequency of radiological abnormalities at the site of a closed diverting loop ileostomy. Method All patients in whom an ileostomy was raised and later closed during a 5‐year period formed the study group. When colorectal cancer surveillance computed tomography (CT) was undertaken the images were scrutinized and graded as to defined anatomical abnormalities. Results One hundred and seventy‐nine patients had an ileostomy, of which 92 were diverting. Fifty‐nine (64%) were closed at various intervals (median time to closure 6 (2–22) months and 43 underwent a surveillance CT at 1–3 (median 2) years. At 1 year an abnormality (atrophy or defect) at the site of closure was seen in 16 (37%) CT scans. These were more frequent with increasing duration of follow‐up. One asymptomatic hernia was detected at 2 years but there was no deterioration in the abdominal wall at 3 years when compared with that at 2 years. Conclusion Abnormalities in the abdominal wall at the site of a closed diverting ileostomy are common but true herniation is unusual. The routine use of prophylactic mesh at ileostomy closure may be unnecessary.     

一针法回肠造口在后期回肠造口还纳手术中应用价值的前瞻性分析

目的:探讨一针法回肠造口在后期回肠造口还纳手术中的应用价值。方法:采用前瞻性随机对照研究方法。选取2016年1月至2020年7月郑州大学附属肿瘤医院收治的141例行直肠癌低位前切除+预防性回肠造口术病人的临床病理资料,剔除未行造口还纳手术病人14例,最终入组127例。按照随机数字表法将病人分为两组。行一针法回肠造口设为...     

The outcome of loop ileostomy closure: a prospective study

Background The use of a loop ileostomy is an effective method to protect pelvic anastomoses, although there is some debate as to the routine use of a stoma. A second operation is required to close the stoma, with potential complications. Objective The aim of this study was to assess prospectively the morbidity of closure of loop ileostomy. Method All patients scheduled for loop ileostomy closure over a 12‐month period were included. The patient demographics, operative technique, complications and length of stay were recorded prospectively. Results Fifty consecutive patients (28 males and 22 females) with a median age (interquartile range, IQR) of 56 (42–73) years underwent closure of loop ileostomy, at a median time (IQR) of 29 (18–48) weeks after formation. Twelve patients (24%) developed complications: six (12%) had intestinal obstruction of which one required a laparotomy, four (8%) had wound infections of which one required re‐operation, one (2%) had an ileal anastomotic leak and subsequently died and one (2%) died from a myocardial infarction. The median length (IQR) of hospital stay was 8 (7–10) days. Conclusion We have demonstrated that a quarter of patients develop complications after loop ileostomy closure. The majority of these are minor. Methods to reduce the number of complications, such as optimum time for closure and distal limb irrigation techniques, need to be studied.     

回盲部置管造瘘在低位直肠癌保肛术中的应用（附30例报道）

目的探讨回盲部置管造瘘在低位直肠癌保肛术中的应用。方法回顾性分析我院2005年4月至2009年4月30例低位直肠癌保肛术运用回盲部置管造瘘患者的临床资料。结果 30例均未发生吻合口漏。结论选择在低位直肠癌保肛术中运用回盲部置管造瘘术有利于降低吻合口漏的发生。     

选择性预防末端回肠造瘘在腹腔镜低位直肠癌保肛手术中的应用价值

目的:探讨选择性预防末端回肠造瘘在腹腔镜低位直肠癌保肛术中对降低吻合口漏发生率的临床价值。方法:回顾分析为109例患者行腹腔镜低位直肠癌保肛手术的临床资料,其中40例行预防性末端回肠造瘘术,69例未行末端回肠造瘘术,对比两组患者术后情况。结果:造瘘组术后无一例发生吻合漏,术后肛门排气时间平均(1.3±0.4)d,术后进食时间平均(1.8±0.4)d,术后盆腔引流管拔除时间平均(6.2±1.5)d,术后平均住院(8.0±1.5)d,治疗费用平均(3.2±0.3)万元。未造瘘组患者术后9例(13.0%)发生吻合口漏,术后肛门排气时间平均(5.1±0.6)d,术后进食时间平均(5.7±0.3)d,术后盆腔引流管拔除时间平均(8.3±3.8)d,术后平均住院(14.2±3.6)d;治疗费用平均(4.3±0.8)万元。两组术后观察指标差异均有统计学意义。结论:低位直肠癌保肛术中选择性预防末端回肠造瘘可有效降低吻合口漏的发生率,尤其高龄、全身情况较差等不利于低位吻合的患者。但术者应进行个体化选择,同时严格遵循无瘤原则、合理选择病例、精细操作可使更多的低位直肠癌患者获得保留肛门的机会。     

腹腔镜低位和超低位直肠癌保肛根治术中改良襻式回肠末端造瘘的应用价值

目的 探讨腹腔镜低位和超低位直肠癌保肛根治术中预防性使用改良襻式回肠末端造瘘的临床应用价值。方法 回顾性分析2010年1月至2012年6月江苏省苏北人民医院收治的108例直肠癌患者的临床资料。所有患者采用腹腔镜低位或超低位直肠癌保肛根治术,其中53例采用预防性改良襻式回肠末端造瘘（预造瘘组）,55例未采用预防性改良襻式回肠末端造瘘（未造瘘组）。对两组患者术中和术后情况进行比较研究。计量资料采用用x±s表示,组间比较采用t检验;计数资料采用率或构成比表示,组间比较采用X2检验或Fisher确切概率法。结果预造瘘组和未造瘘组患者手术时间分别为（185±14）min和（154±12）min,术中出血量分别为（31±26）ml和（28±19）ml,两组比较,差异无统计学意义（t=2.34,1.82,P〉0.05）;术后肛门排气时间分别为 （1.1±0.3）d和（4.2±0.6）d,术后进食时间分别为（1.1±0.2）d和（4.3±0.6）d,盆腔引流管拔出时间分别为（5.2±1.0）d和（8.4±3.9）d,两组比较,差异有统计学意义（t=7.25,28.12,15.34,P〈0.05）;并发症发生率分别为5.7%（3/53）和21.8%（12/55）,吻合口瘘发生率分别为0和12.7%（7/55）,两组比较,差异有统计学意义（P〈0.05）;术后住院时间分别为（7.2±1.4）d和（12.9±4.4）d,治疗费用分别为（3.0±0.2）万元和（3.8±0.7）万元,两组比较,差异有统计学意义（t=34.01,7.83,P〈0.05）。结论 对腹腔镜低位和超低位直肠癌保肛根治术患者施行预防性改良襻式回肠末端造瘘,能有效降低吻合口瘘的发生,有利于患者快速康复。     

左半结肠切除一期吻合加回肠末端造瘘治疗老年梗阻性左半结肠癌的临床效果

目的分析左半结肠切除一期吻合加回肠末端造瘘治疗老年梗阻性左半结肠癌的临床效果。 方法回顾性分析2014年1月至2017年6月80例行左半结肠切除一期吻合术患者的临床资料,根据左半结肠切除一期吻合术后是否加行回肠末端造瘘手术分为研究组(加行回肠末端造瘘手术,39例)和对照组(未加行回肠末端造瘘手术,41例)。数据采用SPSS 20.0统计软件进行分析,患者术中术后各项指标以( ±s)表示,组间比较采用独立t检验。术后并发症的发生情况采用χ²检验。以P<0.05表示差异具有统计学意义。 结果两组患者术中出血量相比,差异无统计学意义(P>0.05);研究组患者手术时间较对照组显著延长(P<0.05);研究组患者术后首次排气时间、首次进食时间、引流管拔出时间以及住院时间分别为(2.5±0.9) d、 (2.5±0.7) d、 (5.7±1.5) d、 (14.3±1.8) d,较对照组均显著缩短,差异具有统计学意义(P<0.05)。研究组吻合口漏及总并发症发生率分别为2.6%、17.9%,显著低于对照组(17.1%、41.5%),差异具有统计学意义(P<0.05)。两组患者术后存活率分别为92.3%、 90.2%,差异无统计学意义(P>0.05)。 结论左半结肠切除一期吻合联合回肠末端造瘘,可促进梗阻性左半结肠癌患者进术后恢复,缩短住院时间,减少术后并发症,值得在临床推广使用。     

Adenocarcinoma arising at ileostomy sites: Two cases and a review of the literature

Total colectomy with ileostomy placement is a treatment for patients with inflammatory bowel disease or familial adenomatous polyposis (FAP). A rare and late complication of this treatment is carcinoma arising at the ileostomy site. We describe two such cases: a 78-year-old male 30 years after subtotal colectomy and ileostomy for FAP, and an 85-year-old male 50 years after colectomy and ileostomy for ulcerative colitis. The long latency period between creation of the ileostomies and development of carcinoma suggests a chronic metaplasia due to an irritating/inflammatory causative factor. Surgical excision of the mass and relocation of the stoma is the mainstay of therapy, with possible benefits from adjuvant chemotherapy. Newly developed lesions at stoma sites should be biopsied to rule out the possibility of this rare ileostomy complication.     

Incisional hernia following closure of loop ileostomy: The main predictor is the patient,not the surgeon

Background

Incisional hernia at the ileostomy site occurs in 0–48% of patients undergoing loop ileostomy closure. Risk factors for ileostomy-site hernia are not currently well understood. We explored the predictive value of patient and clinical factors for ileostomy-site hernias.

预防性回肠造口对腹腔镜直肠癌保肛患者术后肛门功能和心理因素状况的影响

目的探讨预防性造口对腹腔镜直肠癌保肛患者术后肛门功能、生活质量以及心理状况的影响。方法收集2018年9月至2020年9月62例行腹腔镜下直肠癌低位前切除术(L-LAR)患者的临床资料,根据术式不同将其分为末端回肠造口组(n=25例)和未造口组(n=37例)。采用SPSS19.0统计软件分析数据,围手术期相关指标、大便失禁评分、生活质量核心量表、健康问卷评分量表等计量资料以(x±s)表示,采用独立样本/检验,并发症等计数资料用χ²检验。P<0.05为差异有统计学意义。结果两组患者术后Wexner大便失禁评分均逐渐降低,造口组改善更为显著(P<0.05)。生存质量量表评分中,造口组患者躯体功能评分在术后1、3个月较高,总体健康状况评分在术后1、3、6个月均较高,腹泻评分在术后1、3个月均低于未造口组(P<0.05)。造口组患者广泛焦虑障碍量表评分在术后1、3个月较高,(P<0.05),在造口还纳后焦虑心理消失,未造口组患者术后均无焦虑心理。健康问卷抑郁量表评分两组患者在各随访时间点比较差异无统计学意义(P>0.05)。结论预防性造口有助于患者术后肛门功能的更快恢复、短期内的生活质量更好且不会造成患者心理抑郁,但会引起患者轻度焦虑,该心理状态在造口还纳后消失。     

端侧吻合与反式侧侧吻合在腹腔镜右半结肠癌根治术后近期并发症中的比较

目的比较分析回结肠端侧吻合与反式侧侧吻合在腹腔镜辅助右半结肠癌根治术中的并发症发生情况。方法选择郑州大学附属肿瘤医院普外科在2018年3月-2019年10月同一医疗组收治的104例右半结肠癌患者作为研究对象,采用抽签法将所有患者随机分为观察组和对照组,每组各52例,观察组采用回结肠端侧吻合,对照组采用回结肠反式侧侧吻合,统计两组患者手术时间、吻合口瘘、肠梗阻及吻合口狭窄例数、术后首次排气时间、排便时间等,比较分析两种不同吻合方式术后相关并发症发生情况。应用统计软件SPSS22.0进行统计学分析,计数资料以例(%)表示,计量资料以均数±标准差(Mean±SD)表示,两组比较采用独立样本t检验,计数资料比较采用χ^2检验。结果对两组患者手术治疗后的情况进行比较,观察组与对照组患者在手术时间、首次排气时间、首次排便时间和术中出血量方面,差异无统计学意义(P>0.05)。手术以后观察组患者吻合口瘘、吻合口狭窄、吻合口出血、肠梗阻等并发症的总发生率为3.84%(2/52),对照组的并发症发生率为15.38%(8/52),两组在术后总并发症方面有统计学意义(χ^2=3.983,P=0.046)。结论在腹腔镜辅助右半结肠癌根治术中,选择采用回结肠端侧吻合为主的吻合方式术后并发症发生率较低,为使患者能获得更好的治疗效果,可优先考虑此术式。     

Factors Related to Anastomotic Dehiscence and Mortality After Terminal Stomal Closure in the Management of Patients with Severe Secondary Peritonitis

Introduction  Management of severe secondary peritonitis (SSP) may require intestinal resections and bowel exteriorization due to an unacceptable high risk for anastomotic dehiscence (AD). Bowel exteriorization can be achieved through loop or terminal stomas. There are no studies addressing the fate of these latter. Our aim was to determine factors associated with AD and mortality in patients submitted to restoration of intestinal continuity after creation of terminal stomas as part of their operative management for SSP. Patients and Methods  We analyzed prospectively collected databases on all consecutive patients with SSP submitted to restoration of intestinal continuity after having had terminal ileostomies (TI) or terminal colostomies (TC) as part of their operative management during a 30-month period. Several patient and disease and operative variables were evaluated as factors related to AD and mortality in this group of patients. Univariate statistical comparisons were made using Student’s t test for continuous variables and chi-square test when categorical variables were compared. Multivariate analyses were also performed. Results  A total of 72 male patients and 36 female patients were included in the study; 54 had TI and 54 had TC. Median number of operations performed as part of their management for SSP (prior to stomal closure) was 2 (range, 1–15). A total of 76 (70%) had had diffuse peritonitis, and 39 (36%) required management with an open abdomen (26 of them with a skin-only closure technique). Median time interval between stomal creation and closure was 190 days (range, 14–2,192). Stapled and hand-sewn anastomoses were done in 24 and 84 patients, respectively. AD occurred in 11 patients (10%). Univariate analyses disclosed age ≥50 years (p < 0.05), high American Society of Anesthesiologists (ASA) score (≥3; p < 0.01), history of chronic renal failure (p < 0.04), history of diffuse peritonitis (p < 0.05), management with an open abdomen (p < 0.05), and lower preoperative hemoglobin values (p < 0.05) as risk factors for AD. Only age ≥50 years prevailed after multivariate analyses. A total of seven patients died (6%). Factors associated with mortality were age ≥65 years (p < 0.02), high ASA score (≥3; p < 0.01), preoperative use of total parenteral nutrition (p < 0.02), lower preoperative hemoglobin values (p < 0.05), time interval between stomal creation and closure <3 months (p < 0.01), AD (p < 0.02), and need for reoperation after stomal closure (p < 0.02). After multivariate analyses, time interval between stomal creation and closure <3 months and need for reoperation were the only ones that prevailed as independent risk factors for mortality (p < 0.05). Conclusions  Although several variables were related to AD and mortality, waiting at least >3 months before attempting restoration of intestinal continuity seems to be the best approach and a practical recommendation in this group of challenging patients.     

The value of patient-reported outcomes in colon and rectal surgery

Quality in surgery is often assessed in terms of perioperative complications, such as surgical site infections and readmissions. Although patients are the ultimate end-users of surgical care, the impact of surgical care on aspects of health that are most important to them, such as functional status, is rarely assessed. Value is in the eye of the beholder. Patient-reported outcomes provide patients a voice in the assessment of their care quality, and brings greater accountability into the assessment of value.